Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – A systematic review and meta-analysis of randomized controlled trials

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

Cognitive behavioural therapy was delivered in groups only in most studies, except three that combined individual and group sessions and one that used single-person therapy.

“CBTs were delivered by all studies in groups only except three studies which combined individual and group sessions (Soares and Grossi, 2002;Kashikar-Zuck et al., 2005;Garcia-Palacios et al., 2015) and one study with single person therapy (Kashikar-Zuck et al., 2012).”

• cites Soares and Grossi, 2002 sourceNot checked — no full text of the source
• cites Kashikar-Zuck et al., 2005Not checked — no full text of the source
• cites Garcia-Palacios et al., 2015 sourceDisputed

  The Treatment section (page unavailable) describes Garcia-Palacios et al.’s intervention as a group CBT program comprising six two-hour group sessions. It does not describe combined individual and group therapy for this study, contrary to the citing sentence’s classification. (LLM, conf=0.88)

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured

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

One of the excluded Internet-delivered studies had been in the first version of the review.

“One of these studies was included in the first version of the review (Williams et al., 2010).”

• cites Williams et al., 2010 sourceSupported

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

Fibromyalgia syndrome is a clinically defined chronic condition marked by widespread pain, sleep disturbance, cognitive dysfunction and fatigue.

“Fibromyalgia syndrome (FMS) is a clinically defined chronic condition characterized by chronic widespread pain, sleep disturbances, cognitive dysfunction and fatigue (Wolfe et al., 2011).”

• cites Wolfe et al., 2011 sourceSupported

Classified as probably not a substantial claim.

Despite existing research and guidelines, several major questions about the importance of cognitive behavioural therapies in fibromyalgia syndrome remain unresolved.

“Despite a large amount of research and recommendations for the management of FMS by recent evidence-based guidelines (K€ ollner et al.,2017;MacFarlane et al., 2017) some major questions on the importance of CBTs in FMS are not definitely answered:”

• cites K€ ollner et al.,2017Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites MacFarlane et al., 2017 sourcePartly supported

  The Cognitive behavioural therapies section reviews multiple trials, and the EULAR revised recommendations section gives CBT a weak recommendation. The Research priorities section identifies unresolved questions about treatment combinations and who responds to specific therapies, but does not identify the importance of CBT itself as an unanswered major question. No page numbers are available in our copy. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

• AssumptionRests on an assumption: No study has compared the efficacy of different cognitive behavioural therapy types in fibromyalgia syndrome.
• AssumptionRests on an assumption: Whether assessment and reporting of adverse events in cognitive behavioural therapy trials for fibromyalgia syndrome has improved in recent years has not been studied.

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

Two studies were excluded because cognitive behavioural therapy was delivered over the Internet without contact with a psychotherapist.

“We excluded two studies because CBTs were delivered by Internet without any contact with a psychotherapist (Williams et al., 2010;Menga et al., 2014).”

• cites Williams et al., 2010 sourceSupported
• cites Menga et al., 2014Not checked — no full text of the source

Classified as probably not a substantial claim.

Blinding of participants and personnel was not assessed because therapists and patients cannot be blinded to treatment delivery or receipt.

“We excluded the option of 'blinding participants and personnel' because neither therapists nor patients can be blinded to whether they deliver or receive treatment (Williams et al., 2012).”

• cites Williams et al., 2012 sourceSupported

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

One study did not report number and duration of sessions.

“One study did not report the number and duration of sessions (Woolfolk et al., 2012).”

• cites Woolfolk et al., 2012 sourcePartly supported

  The Study Design section (2.1; page unavailable) explicitly reports 10 weekly ACBT sessions, so the claim that the number was not reported is incorrect. The retrieved treatment descriptions do not specify how long each individual session lasted, supporting only the duration portion of the claim. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

Cognitive behavioural therapy approaches may be more acceptable and easier to implement in Western individualist cultures.

“CBTs approaches may be more acceptable and easier to implement in western populations whose cultures are 'individualist' (where individual self-realization is everything and relationships with family and others are subordinate)”

• cites Naeem et al., 2015 sourceSupported

May combine two claims.

Cognitive behavioural therapy approaches may be less acceptable and harder to integrate into daily life for patients from collectivist cultures.

“and less acceptable and more difficult to incorporate into daily lives in patients from 'collectivist' cultures (where networks, kinship and the roles they bring are very important and goals are pursued within those constraints) (Naeem et al., 2015).”

• cites Naeem et al., 2015 sourceSupported

Classified as probably not a substantial claim.

The review's analyses of methodological problems in most included studies support the position that no new trials should be conducted until those critical problems are addressed.

“Our analyses of the methodology problems of most of the studies analysed in this review supports their postulation, that there should be no new trials until these critical problems are addressed (Eccleston and Crombez, 2017).”

• cites Eccleston and Crombez, 2017 sourceSupported

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

Twenty-two studies from the first version were included.

“We included 22 studies from the first version of the review”

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

Seven new studies were included.

“We included seven new studies (Williams et al., 2002;Parra-Delgado and Latorre-Postigo, 2013;Wicksell et al., 2013;Luciano et al., 2014;Mart ınez et al., 2014;Garcia-Palacios et al., 2015;Karlsson et al., 2015).”

• cites Williams et al., 2002Not checked — no full text of the source
• cites Parra-Delgado and Latorre-Postigo, 2013 sourceNot checked — no full text of the source
• cites Wicksell et al., 2013 sourceNot checked — no full text of the source

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

The updated search yielded 561 hits.

“The updated search produced 561 hits.”

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

The new studies added 546 participants.

“These studies added 546 new participants.”

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

One study (Williams et al., 2002) was not in the first version of the review.

“One study (Williams et al., 2002) was not included in the first version of this review.”

• cites Williams et al., 2002Not checked — no full text of the source

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

Median number of sessions was 10 (range 6-60) and median total hours was 18 (range 3-102).

“The median number of sessions was 10 (6-60) and the median total hours was 18 (3-102) h.”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for pain relief of 50% or greater at long-term follow-up (p<0.0001).

“CBTs were statistically significant superior to controls (p-value < 0.0001).”

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

Eighteen included studies were conducted in Europe.

“Eighteen studies were conducted in Europe”

The quote only partly states this claim.

There was no statistically significant difference between CBTs and controls for improvement of health-related quality of life of 20% or greater at long-term follow-up (p=0.08).

“There was no statistically significant difference between CBTs and controls (p-value 0.08).”

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

All included studies except one were outpatient-based.

“All studies but one (Thieme et al., 2003) were outpatient-based.”

• cites Thieme et al., 2003 sourceNot checked — no full text of the source

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

Median cognitive behavioural therapy duration was 10 weeks (range 3-54).

“The median duration of all CBTs was 10 (3-54) weeks.”

May combine two claims.

Two studies included only children and adolescents; the remaining studies included only adults.

“Two studies included only children and adolescents (Kashikar-Zuck et al., 2005;Kashikar-Zuck et al., 2012); the other studies included only adults.”

• cites Kashikar-Zuck et al., 2005Not checked — no full text of the source
• cites Kashikar-Zuck et al., 2012Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

Disease duration in children and adolescents was reported as 3 years in one study.

“Disease duration in children and adolescents was reported to be 3 years in one study (Kashikar-Zuck et al., 2012).”

• cites Kashikar-Zuck et al., 2012Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

Fifteen studies included only women.

“Fifteen studies included only women”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in disability at end of treatment (p=0.007).

“CBTs were statistically significantly superior to controls (p-value 0.007).”

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

Overall, included patients had long disease duration (more than five years) except in three studies reporting less than five years.

“Overall, the studies included patients with a long disease duration (more than five years) except in three studies (Soares and Grossi, 2002;Falcao et al., 2008;Mir o et al., 2011) which reported a disease duration of <5 years.”

• cites Soares and Grossi, 2002 sourceNot checked — no full text of the source
• cites Falcao et al., 2008 sourceNot checked — no full text of the source
• cites Mir o et al., 2011Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

Median participants per cognitive behavioural therapy group was 32 (range 14-207) and per control group was 30.

“The median number of participants in CBTs groups was 32 (14-207), in controls 30 .”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in negative mood at end of treatment (p<0.0001).

“CBTs were statistically significantly superior to controls (p-value < 0.0001).”

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

One study used a cross-over design; the rest used a parallel design.

“One study used a cross-over design (Kashikar-Zuck et al., 2005), the remaining studies used a parallel design.”

• cites Kashikar-Zuck et al., 2005Not checked — no full text of the source

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in negative mood at long-term follow-up (p=0.0008).

“CBTs were statistically significantly superior to controls (p-value 0.0008).”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for improvement of health-related quality of life of 20% or greater at end of treatment (p=0.04).

“CBTs were statistically significantly superior to controls (pvalue 0.04).”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in fatigue at end of treatment (p=0.02).

“CBTs were statistically significant superior to controls (p-value 0.02).”

The quote only partly states this claim.

The standardized mean difference for reduction in negative mood at long-term follow-up was -0.48 (95% CI -0.77 to -0.20).

“SMD was À0.48 (95% CI À0.77 to À0.20).”

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

Ten of the European studies were conducted in Spain.

“of which 10 were conducted in Spain”

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

Six studies used active non-pharmacological controls.

“six studies with active non-pharmacological controls”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in disability at long-term follow-up (p=0.0001).

“CBTs were statistically significant superior to controls (p-value 0.0001).”

May combine two claims.

The analysis included 1236 participants in treatment groups and 1246 in control groups.

“We included a total of 1236 participants in treatment groups and 1246 participants in control groups in the analysis.”

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

The remaining studies compared cognitive behavioural therapy with treatment as usual.

“the remaining studies compared CBTs to treatment as usual.”

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

Median attended cognitive behavioural therapy sessions was 77% (range 42-93%).

“The median of attended CBTs sessions was 77% (range 42-93%).”

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

Twenty-three studies provided traditional cognitive behavioural therapy.

“Twenty-three studies provided traditional CBT”

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

Median percentage of women in cognitive behavioural therapy groups was 100% (range 89-100%).

“The median percentage of women in CBTs groups was 100% (89-100%).”

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

All studies except six were single-centre.

“All studies except six (Oliver et al., 2001;Rooks et al., 2007;Alda et al., 2011;Luciano et al., 2011Luciano et al., , 2014;;Kashikar-Zuck et al., 2012) were single-centre studies.”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for pain relief of 50% or greater at end of treatment (p=0.0003).

“CBTs were statistically significantly superior to controls (p-value 0.0003).”

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

Fourteen studies reported average attendance rates.

“Fourteen studies reported on average attendance rates of participants”

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

Three studies offered acceptance or mindfulness-based therapy.

“three studies offered acceptance/mindfulness-based therapy”

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

Ten studies were conducted in North America (USA) and one in South America (Brazil).

“Ten studies were conducted in North America (USA) (Nicassio et al., 1997;Oliver et al., 2001;King et al., 2002;Williams et al., 2002;Edinger et al., 2005;Kashikar-Zuck et al., 2005, 2012;Rooks et al., 2007;Ang et al., 2010;Woolfolk et al., 2012) and one in South America (Brazil) (Falcao et al., 2008).”

• cites Falcao et al., 2008 sourceNot checked — no full text of the source

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

Two studies each provided self-management education and operant therapy.

“two studies each provided self management education (Oliver et al., 2001;Rooks et al., 2007) and operant therapy (Thieme et al., 2003(Thieme et al., , 2006)).”

• cites Oliver et al., 2001Not checked — no full text of the source
• cites Rooks et al., 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Thieme et al., 2003 sourceNot checked — no full text of the source

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

All studies used live face-to-face contact except one delivered by telephone.

“All studies were conducted by live face-toface contact except one study which was delivered by telephone (voice-to-voice) (Ang et al., 2010).”

• cites Ang et al., 2010 sourceNot checked — no full text of the source

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

Only one study had total treatment time below 5 h and seven had more than 25 h.

“Only one study had a total treatment time <5 h (Ang et al., 2010) and seven studies had a treatment time of >25 h (Wigers et al., 1996;Soares and Grossi, 2002;Thieme et al., 2003;Thieme et al., 2006;Falcao et al., 2008;Castel et al., 2012;Karlsson et al., 2015).”

• cites Ang et al., 2010 sourceNot checked — no full text of the source
• cites Wigers et al., 1996 sourceNot checked — no full text of the source
• cites Soares and Grossi, 2002 sourceNot checked — no full text of the source

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

Five studies used attention controls.

“five studies with attention controls”

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

Median mean age was 47.4 years (range 15.2-55.4).

“The median of the mean age was 47.4 (15.2-55.4)years.”

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

Eighteen studies performed follow-ups at 6 months or longer.

“Eighteen studies performed follow-ups at equal to or greater than 6 months”

May combine two claims.

At end of treatment, long-term CBTs had non-significant effect sizes on pain and disability, and a moderate significant effect on negative mood.

“At end of treatment, the effect sizes of long-term CBTs on pain and disability were not statistically significant, the effect size on negative mood was moderate and statistically significant.”

May combine two claims.

CBTs were superior to controls in pain relief of 50% or greater and reducing negative mood and disability at long-term follow-up.

“and in pain relief of 50% or greater and in reducing negative mood and disability at long-term follow-up.”

May combine two claims.

CBTs with high reported treatment quality had small significant effects on disability and pain, and a moderate significant effect on mood at end of treatment.

“The effect sizes of CBTs with high reported treatment quality on disability and pain at end of treatment were small and statistically significant, the effect size on mood at end of treatment was moderate and statistically significant”

May combine two claims.

CBTs did not differ in efficacy except superiority for coping with pain from recommended drug therapy (pregabalin and/or duloxetine) at the end of treatment and at long-term follow-up.

“CBTs did not differ in efficacy except superiority for coping with pain from recommended drug therapy (pregabalin and/or duloxetine) at the end of treatment and at long-term follow-up.”

May combine two claims.

At long-term follow-up, long-term CBTs had large significant effects on negative mood and disability, and a medium significant effect on pain.

“At long-term followup, the effect sizes of long-term CBTs on negative mood and disability were large and statistically significant and on pain medium and statistically significant.”

May combine two claims.

CBTs with moderate reported treatment quality had small significant effects on negative mood and disability, and a non-significant effect on pain at end of treatment.

“The effect sizes of CBTs with moderate reported treatment quality on negative mood and disability at end of treatment were small and statistically significant, the effect size on pain was not statistically significant.”

The quote only partly states this claim.

CBTs were statistically significantly superior to controls for reduction in fatigue at long-term follow-up (p=0.0005).

“CBTs were statistically significant superior to controls (p-value 0.0005).”

May combine two claims.

In children and adolescents, traditional CBT had a small significant effect on mean pain intensity at end of treatment, and non-significant effects on negative mood and disability.

“The effect size of traditional CBT on mean pain intensity at end of treatment in children and adolescents was small and statistically significant.The effect sizes on negative mood and disability at end of treatment were not statistically significant.”

May combine two claims.

At long-term follow-up, short-term CBTs had non-significant effects on negative mood and disability, and a small significant effect on pain.

“At long-term follow-up, the effect sizes of short-term CBTs on negative mood and disability were not statistically significant.The effect size on pain was small and statistically significant”

May combine two claims.

At long-term follow-up, operant therapy was superior to traditional CBTs in improvement of HRQOL of 20% or greater, reduction in disability, negative mood, pain relief 30% or greater, and coping with pain.

“Operant therapy was superior to traditional CBTs in improvement of HRQOL of 20% or greater (p-value 0.007), reduction in disability (p-value 0.008), of negative mood (p-value 0.005), in pain relief 30% or greater (p-value 0.009) and coping with pain (p-value 0.05).”

May combine two claims.

CBTs were superior to controls in pain relief of 50% or greater, improving health-related quality of life of 20% or greater, and reducing negative mood and disability at the end of treatment.

“CBTs were superior to controls (waiting list, attention control, treatment as usual, other active nonpharmacological therapies) in pain relief of 50% or greater, in improving of health-related quality of life of 20% or greater and in reducing negative mood and disability at the end of treatment”

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

The updated review included three studies using acceptance-based approaches.

“Our updated review could include three studies with acceptance-based approaches.”

The quote only partly states this claim.

The standardized mean difference for reduction in fatigue at long-term follow-up was -0.42 (95% CI -0.65 to -0.18).

“SMD was À0.42 (95% CI À0.65 to À0.18).”

May combine two claims.

At end of treatment, short-term CBTs had small significant effects on negative mood and disability, and a non-significant effect on pain.

“At end of treatment, the effect sizes of short-term CBTs on negative mood and disability were small and statistically significant, the effect size on pain was not statistically significant.”

May combine two claims.

In adults, traditional CBT had small significant effects on mean pain intensity, negative mood, and disability at end of treatment.

“The effect sizes of traditional CBT on mean pain intensity, negative mood and disability in adults at end of treatment were small and statistically significant”

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

Two reviewers independently extracted study data using a purpose-designed extraction form.

“Two authors extracted data on the studies (including the methods, settings, participants, interventions, outcomes, results, funding, conflicts of interest) independently using a specially designed data extraction form (KB, WH).”

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

Two reviewers independently classified each study's cognitive behavioural therapy type.

“The classification of the CBT delivered by the studies into self-management, traditional CBT, operant therapy and acceptance-based CBTs was rated independently by two authors (KB, WH) based on the details of therapy as reported by the authors and on the classification of CBTs as outlined in TYPES OF INTERVENTION.”

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

Acceptance and commitment therapy has strong research support for chronic or persistent pain according to Division 12 of the American Psychological Association.

“Acceptance and commitment therapy (ACT) received strong research support for chronic/ persistent pain by the Division 12 of the American Psychological Association (Society of Clinical Psychology, 2017).”

• cites Society of Clinical Psychology, 2017Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

Two reviewers independently rated reported treatment quality.

“Reported treatment quality was rated independently by two authors (KB, WH).”

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

One reviewer entered data into RevMan 5.3 and a second reviewer validated the entries.

“One author (WH) entered data into Review Manager (RevMan) 5.3 (RevMan, 2014), and a second author (KB) validated the entries.”

• cites RevMan, 2014Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

Two reviewers independently assessed risk of bias for each included trial.

“Two review authors (KB, WH) independently assessed the risk of bias of each included trial.”

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

There is no universally accepted definition of which techniques constitute cognitive behavioural therapy.

“However, there is no universally accepted definition of which techniques constitute CBT (Morley, 2011).”

• cites Morley, 2011 sourceNot checked — no full text of the source

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

Disagreements were resolved by discussion, with a third reviewer consulted if needed.

“We resolved disagreements by discussion, if necessary a third review author (PW) was consulted.”

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

Cognitive behavioural therapies are considered the gold-standard psychological treatment for fibromyalgia patients by Division 12 of the American Psychological Association.

“CBTs are the 'gold-standard' psychological treatment for FM patients according to the Division 12 of the American Psychological Association (Society of Clinical Psychology, 2017).”

• cites Society of Clinical Psychology, 2017Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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

Two reviewers independently screened titles and abstracts and selected studies using inclusion and exclusion criteria.

“Two review authors (KB, WH) independently scrutinized all the titles and abstracts and selected studies based on inclusion and exclusion criteria.”

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

Treatment quality was assessed with a five-criteria scale designed for psychological pain treatment studies.

“We assessed the quality of the treatment using five criteria (treatment content and setting, treatment duration, manualization of the treatment, adherence of the therapist to the manual, therapist training and client engagement) on a quality rating scale designed specifically for application to psychological treatment studies in pain.”

• cites Yates et al., 2005 sourceNot checked — no full text of the source

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

Risk-of-bias disagreements were resolved by discussion and consensus, with a third reviewer as arbiter if needed.

“Disagreements were resolved by discussion and consensus, otherwise a third review author (PW) acted as arbiter.”

May combine two claims.

Psychological therapies may reduce key symptoms and improve daily functioning in fibromyalgia syndrome.

“Therefore, psychological therapies may help to reduce key symptoms and improve daily functioning.”

Classified as probably not a substantial claim.

The label cognitive behavioural therapies includes classical and operant therapies, psychoeducation, different cognitive behavioural therapies and acceptance-based therapies.

“Within the label 'CBTs', 'classical', operant therapies, psychoeducation, different types of cognitive behavioural therapies and acceptance-based therapies are included (Kaiser and Nilges, 2015).”

• cites Kaiser and Nilges, 2015 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

A prior systematic review found that higher treatment dose was associated with better outcome.

“One systematic review found that higher treatment dose was associated with better outcome (Glombiewski et al., 2010).”

• cites Glombiewski et al., 2010 sourceNot checked — no full text of the source

The quote only partly states this claim.

The quality of evidence for improvement of health-related quality of life of 20% or greater at long-term follow-up was moderate, downgraded by one level due to inconsistency.

“The quality of evidence was downgraded by one level to moderate because of inconsistency.”

May combine two claims. The quote only partly states this claim.

The effect size for reduction in fatigue at end of treatment was small and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was small and there was a clinically relevant benefit by CBTs.”

The quote only partly states this claim.

The quality of evidence for improvement of health-related quality of life of 20% or greater at end of treatment was moderate, downgraded by one level due to inconsistency.

“The quality of evidence was downgraded by one level to moderate because of inconsistency.”

The quote only partly states this claim.

There was a clinically relevant benefit by CBTs for improvement of health-related quality of life of 20% or greater at end of treatment according to predefined categories.

“According to the predefined categories there was a clinically relevant benefit by CBTs.”

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

The quality of evidence for reduction in negative mood at end of treatment was high.

“The quality of evidence was high.”

May combine two claims.

The effect size for reduction in negative mood at end of treatment was small and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was small and there was a clinically relevant benefit by CBTs.”

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

The quality of evidence for reduction in fatigue at end of treatment was high.

“The quality of evidence was high.”

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

The quality of evidence for acceptability at end of treatment was high.

“The quality of evidence was high.”

The quote only partly states this claim.

There was no clinically relevant benefit by CBTs for pain relief of 50% or greater at long-term follow-up according to predefined categories.

“According to the predefined categories there was no clinically relevant benefit by CBTs.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). The quote only partly states this claim.

The quality of evidence for pain relief of 50% or greater at long-term follow-up was high.

“The quality of evidence was high.”

Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). The quote only partly states this claim.

The quality of evidence for reduction in negative mood at long-term follow-up was moderate, downgraded by one level due to inconsistency.

“The quality of evidence was downgraded by one level to moderate because of inconsistency.”

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

The quality of evidence for reduction in disability at end of treatment was high.

“The quality of evidence was high.”

May combine two claims. The quote only partly states this claim.

The effect size for reduction in disability at end of treatment was small and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was small and there was a clinically relevant benefit by CBTs.”

The quote only partly states this claim.

The quality of evidence for safety at end of treatment was moderate, downgraded by one level due to low event rate.

“The quality of evidence was moderate downgraded by one level due to low event rate.”

May combine two claims. The quote only partly states this claim.

The effect size for reduction in negative mood at long-term follow-up was small and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was small and there was a clinically relevant benefit by CBTs.”

Probably not a substantial claim: may not pass S4 (based).

More intensive therapies, up to 75 hours, might improve long-term outcomes.

“More intensive therapies (up to 75 h) might improve long-term outcomes.”

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

The quality of evidence for reduction in fatigue at long-term follow-up was high.

“The quality of evidence was high.”

May combine two claims.

Subgroup analyses demonstrated that reductions in mean pain intensity, negative mood, and disability were detectable for traditional CBTs and acceptance-based CBTs at end of treatment and at long-term follow-up, and for operant therapy at follow-up, but not for operant therapy or self-management education programs at end of treatment if compared to nonpharmacological controls.

“Subgroup analyses demonstrated that a reduction in mean pain intensity, negative mood and disability were detectable for traditional CBTs and acceptancebased CBTs at end of treatment and at long-term follow-up and for operant therapy at follow-up, but not for operant therapy or self management education programs at end of treatment if compared to nonpharmacological controls.”

May combine two claims.

The review used only reported data for quality assessment and did not request further details from authors in order to avoid response bias.

“We relied on the reported data for quality assessment and did not ask authors for further details because we did not want to introduce a 'response' bias.”

• AssumptionThe authors state this as an assumption: Requesting further details from study authors would introduce response bias.

May combine two claims. The quote only partly states this claim.

The effect size for reduction in fatigue at long-term follow-up was small and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was small and there was a clinically relevant benefit by CBTs.”

May combine two claims. The quote only partly states this claim.

The effect size for reduction in disability at long-term follow-up was moderate and there was a clinically relevant benefit by CBTs.

“According to the predefined categories, the effect size was moderate and there was a clinically relevant benefit by CBTs.”

May combine two claims. The quote only partly states this claim.

The quality of evidence for reduction in disability at long-term follow-up was moderate, downgraded by one level due to inconsistency.

“The quality of evidence was downgraded by one level to moderate because of inconsistency.”