Authors' objectives

To answer two broad questions: 1. Is cognitive behavioural therapy (including behaviour therapy and biofeedback) an effective treatment for chronic pain, i.e. is it'better' than no treatment? 2. Is cognitive behavioural therapy more effective than alternative active treatments?

Searching

Four computer abstracting services were selected and their yields compared; MEDLINE, PsycLIT, EMBASE and the Social Science Citation Index (SSCI). Reference lists and bibliographies were searched from all retrieved articles and relevant published reviews. The final list was cross-checked with the PARED database. Studies published in full, in peer reviewed journals between 1974 and 1996 only were included.

Study selection

Assessment of study quality

The authors did not state that they assessed quality.

Data extraction

Data were extracted by two or three coders and the reliability of coding was assessed by computing Kappa or percentage agreement for categorical data, and the intraclass correlation for continuous measures. Differences between coders were resolved by consensus. Data were extracted on randomisation quality, treatments, patient group, location and sample size.

Methods of synthesis

Results of the review

Thirty-three papers contained data from 30 trials, including 1672 patients (or 1626 according to table 3), some papers reported additional or follow-up data. Five trials were excluded from the statistical analysis as the authors were unable to provide data suitable for computing effect size statistics. This left 25 controlled trials for analysis.

When compared with the Waiting List Control (WLC) conditions cognitive-behavioural treatments were associated with significant 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.

Authors' conclusions

Active psychological treatments based on the principle of cognitive behavioural therapy are effective.

CRD commentary

The review question was clear and the search strategy seems complete and appropriate. The inclusion criteria seem well chosen and inclusion of studies was assessed by each of the authors. Authors did not report whether methodological quality was assessed. Data abstraction was performed correctly, and the synthesis of results is presented clearly and completely. Considering all of these factors the results presented appear to support the authors conclusions.

Implications of the review for practice and research

This review raised methodological issues which should be considered in the design of future trials. Psychological treatment of chronic pain is complex, lengthy and variable, outcomes cannot be easily dichotomized and it is rarely possible to blind patients and therapists to treatment conditions.

Bibliographic details

Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999; 80(1-2): 1-13. [PubMed: 10204712]

Other publications of related interest

1. Hedges LV, Olkin I. Statistical methods for meta-analysis. Orlando (FL): Academic Press; 1985. 2. Rosenthal R. Parametric measures of effect size. In: Cooper H, Hedges LV, editors. The handbook of research synthesis. New York: Russell Sage Foundation; 1994. p. 231-44. 3. Hunter JE, Schmidt FL. Methods of meta-analysis. Beverly Hills (CA): Sage Publications; 1990.

This additional published commentary may also be of interest. White AR. Psychological therapies have a place in treating chronic pain. FACT 2000;5:141-2.

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Behavior Therapy; Chronic Disease; Cognitive Therapy; Female; Humans; Male; Middle Aged; Pain /etiology; Pain Management; Randomized Controlled Trials as Topic; Research Design; Sample Size

AccessionNumber

11999000758

Database entry date

22/09/2000

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.