Cronic pain meta-analisis

Pain 80 (1999) 1–13

Review Article

Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache
Stephen Morley a,*, Christopher Eccleston b, Amanda Williams c
a

Division of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK bDepartment of Psychology, University of Bath, Bath, UK c United Dental and Medical School, University of London, London, UK Received 16 March 1998; received in revised form 21 July 1998; accepted 23 October 1998

Abstract A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behaviouraltreatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated withsignificant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains werenot significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials. © 1999 InternationalAssociation for the Study of Pain. Published by Elsevier Science B.V. Keywords: Systematic review; Meta-analysis; Chronic pain; Cognitive behavioural therapy

1. Introduction Behavioural and cognitive treatments for chronic pain have become established in the 30 years since their exposition (Fordyce et al., 1968, 1973; Turk et al., 1983). There are many published open trials of treatment but feweruse control groups in which patients are randomized to treatments. Reviews, however, conclude that there is strong, if not overwhelming evidence for the efficacy of cognitive behavioural therapy (CBT) in restoring function and mood and in reducing pain and disability-related behaviour. Recently, one reviewer regretted that CBT is not provided

* Corresponding author. Tel.: +44-113-233-2733; fax:+44-113-2433719; e-mail: s.j.morley@leeds.ac.uk

routinely for chronic pain sufferers rather than medical and physical interventions for which there is less evidence of efficacy (Loeser, 1991). Other overviews of pain management are more critical (Ashburn, 1996). However, to date there has been no systematic review and meta-analysis of randomized controlled trials. Of the three extantmeta-analyses of CBT for chronic pain, one (Malone and Strube, 1988) combined physical and psychological treatment for chronic pain including headache and dental pain; a second (Flor et al., 1992) restricted its scope to psychological treatments and excluded headache; the most recent (Turner, 1996) selected a small sample of randomized controlled trials (RCT) of educational, behavioural and cognitiveinterventions for chronic low-back pain in the setting of primary care. Both meta-analyses, which included uncontrolled studies, found

0304-3959/99/$ - see front matter © 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S03 04-3959(98)002 55-3

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S. Morley et al. / Pain 80 (1999) 1–13

the largest effect sizes for treatment in outcome measures...